Assisting in obstetrics and gynecology

The branch of medicine that deals with pregnancy, labor, and the postpartum period is known as obstetrics, and the branch of medicine that deals with diseases of the reproductive system in women is called gynecology. Frequently, a provider practices both specialties and is known as an OB/GYN provider. The assessment of the female reproductive system is an important part of healthcare. Patients are often hesitant and uncomfortable talking about sexual matters, so they wait until the symptoms are uncomfortable or the disease has advanced before they seek medical care. The medical assistant needs to be familiar with signs and symptoms of the diseases and conditions related to this specialty. In addition, the medical assistant must be aware of the patient’s emotional state and must give support when needed.

In this chapter, we review the anatomy and physiology of the female reproductive system and diseases and disorders of the reproductive system. We will also discuss the medical assistant’s role in gynecologic and obstetric procedures. A medical assistant has two roles in these situations:

• Assist the provider in any way needed
• Be there for the patient by helping her to be as comfortable as possible during her time in the healthcare facility

When we make patients feel comfortable, we help to establish a trusting relationship where patients will be able to share the information the provider needs in order to give them the best possible care.

Anatomy and physiology of the female reproductive system

The anatomy of the female reproductive system involves internal genitalia, external genitalia, and breasts. The gynecologic examination involves the assessment of each of those physical structures. The physiology of those structures can change depending on what is going on at the time. The anatomy and physiology of the female reproductive system are discussed in the following sections.

Anatomy of the female reproductive system

The anatomy of the female reproductive system can be divided into two parts. Parenchymal or primary tissue produces sex cells for reproduction. Stromal or secondary tissue includes all of the glands, nerves, ducts, and other tissues that serve a supportive function in producing, maintaining, and transmitting these sex cells.

In females, the gonads are the ovaries. They produce ova, the female gametes. From menarche, the first menstrual period, to menopause, the cessation of menstruation, mature ova are produced. The ovaries are small, almond-shaped, paired organs located on either side of the uterus in the female pelvic cavity. They are attached to the uterus by the ovarian ligaments. The ovaries lie close to the opening of the fallopian tubes, the ducts that convey the ova from the ovaries to the uterus. Fallopian tubes are also called oviducts or uterine tubes.

Once the mature ovum has been released, it is drawn into the fimbriae, the feathery ends of the fallopian tube. These tubes are about 1 cm in diameter and 10 to 12 cm long. The ovum travels down the fallopian tube to the uterus. The fallopian tubes and the ovaries make up what is called the uterine adnexa, or accessory organs, of the uterus.

Once the ovum has moved down the fallopian tube, it is secreted into the uterus or womb. The uterus is a pear-shaped organ that is designed to nurture a developing embryo/fetus. The uterus is composed of three layers:

• Outer layer, called the perimetrium
• Middle or muscle layer, called the myometrium
• Lining, called the endometrium

As a whole, it can be divided into several areas:

• Corpus or body, the large central area
• Fundus, the raised area at the top of the uterus between the outlets for the fallopian tubes
• Cervix, the narrowed lower area, often referred to as the neck of the uterus; the opening of the cervix is called the cervical os

The vagina is a 10-cm (4-inch) muscular, tubelike structure that extends from the uterine cervix to the vulva (the external genitalia). It connects the internal reproductive structures with the external reproductive structures. The vagina serves as the passageway for the endometrium during menstruation, receives the penis during intercourse, and is the birth canal during the delivery of a baby.

The external female genitalia collectively are called the vulva; it consists of the orifice , hymen, labia majora , labia minora , clitoris , and perineum . The paired glands in the vulva that secrete a mucous lubricant for the vagina are the Bartholin glands. The mons pubis is a fatty cushion of tissue over the pubic bone.

The breasts, or mammary glands, function to secrete milk. The breast tissue is composed of glandular, milk-producing, fatty, and fibrous tissue. The nipple of the breast is the mammary papilla, and the darker-colored skin surrounding the nipple is the areola.

Physiology of the female reproductive system

When a girl enters puberty, one of the many changes that occur is menarche. Menstruation is a normal body process that occurs in every female. It is the physiologic means by which the body rids itself of the thickened endometrial wall that develops during the average 28-day cycle. The menstrual cycle involves a series of events controlled by hormones from the pituitary gland and the ovaries. The cycle is divided into the follicular phase, the luteal phase, and the menstrual phase.

The follicular phase is also called the proliferative phase. In this phase, hormones are secreted to mature a Graafian follicle in an ovary that contains an ovum. The mature ovarian follicle secretes estrogen, which stimulates the growth of the endometrium. It takes approximately 9 days for the Graafian follicle to ripen and bulge out from the ovarian wall. The ovarian wall becomes thinner as the follicle enlarges until it bursts, releasing the ovum into the abdominal cavity. Expulsion of the ovum ends the follicular phase. The fallopian fimbriae begin their wavelike motion to fan the ovum into the fallopian tube. The rupture spot on the ovary, now called the corpus luteum, begins to secrete progesterone. Ovulation causes a rise in body temperature, and some women experience cramping and tenderness in the lower abdominal area at this time due to the rupture of the Graafian follicle.

The luteal phase is also called the secretory phase. Once ovulation is complete, the luteal phase begins. During this phase, progesterone secreted by the corpus luteum causes extensive growth of the endometrium as it prepares for a possible pregnancy. If conception occurs, the corpus luteum continues to secrete progesterone until the placenta is well established. The corpus luteum can secrete progesterone and human chorionic gonadotropin (hCG) to maintain the pregnancy. If conception does not occur, hCG is not secreted, and the corpus luteum atrophies. Without increased levels of progesterone and hCG, the endometrium breaks down, and menstruation begins.

In the menstrual phase, the uterus contracts to shed the lining of the uterus, made up of necrotic endometrial tissue, mucus, and blood from endometrial engorgement. A woman may experience cramping, pain, and irritability. This phase usually lasts approximately 5 days.

The female reproductive system

Pregnancy and delivery

Pregnancy begins with the fertilization of an ovum by a sperm, often in the fallopian tube, as the ovum travels toward the uterus. Conception is usually the result of sexual intercourse. However, other methods of conception are possible if the couple has difficulty conceiving. These methods are discussed in the Disorders of the Female Reproductive System section.

The fertilized egg, or zygote, divides as it moves through the fallopian tube to the uterus. In the first few days after fertilization, when the zygote has become a solid ball of cells from repeated divisions, it is called a morula. As it continues to develop, it moves from the fallopian tube into the uterus and implants into the uterine wall. At this point, it is called a blastocyst.

During implantation, the zygote functions as an endocrine gland by secreting hCG. The function of the hormone is to stop the corpus luteum from deteriorating. The corpus luteum allows the continued production of estrogen and progesterone to support the pregnancy and prevent menstruation. From the third to the eighth week of development, the organism is called an embryo. From the ninth through the thirty-eighth week of development (a normal length for gestation, or pregnancy), it is called a fetus.

At the same time that the embryo is developing, extraembryonic membranes are forming to sustain the pregnancy:

• The amnion and the chorion form the inner and outer sacs that contain the embryo.
• The fluid that forms inside the amnion is the amniotic fluid. It cushions the embryo, protects it against temperature changes, and allows it to move.
• The placenta is a highly vascular structure that acts as a physical communication between the mother and the embryo.
• The umbilical cord is the tissue that connects the embryo to the placenta (and hence to the mother). When the baby is delivered, the umbilical cord is cut, and the baby is then dependent on his or her own body for all physiologic processes. The remaining “scar” is the umbilicus or navel. The delivery of an infant is termed parturition.

Life span changes

As females age, several changes occur to the reproductive system. The following sections discuss some of those changes.

Changes in children

Significant changes occur in the female reproductive system during puberty, typically between the ages of 10 and 14. These physical changes are driven by the levels of hormones that are produced by the pituitary gland; luteinizing hormone and follicle-stimulating hormone. Those hormones stimulate the production of the sex hormones. The increased level of estrogen stimulates the maturation of the breasts, ovaries, uterus, and vagina. In the United States, breast development usually occurs between the ages of 8 and 13. Two to three years later, menarche occurs. In addition, during puberty, body shape changes. There is an increase in body fat that accumulates in the hips and thighs.

Menstrual disorders are common problems during puberty. These include irregular menstruation, dysmenorrhea, and amenorrhea. It is not uncommon for periods to be irregular at the start of menstruation. Primary dysmenorrhea (not caused by another medical condition such as endometriosis) is usually treated with nonsteroidal anti-inflammatory drugs (NSAIDs) or oral contraceptives. Primary amenorrhea is when a girl, who is 16 years old, has never had a period. This can occur when there is an anatomic abnormality, which can be corrected with surgical intervention. If there are no anatomical abnormalities, amenorrhea treatments could include hormone treatments, oral contraceptives, changes in diet, and an evaluation for hormone-secreting tumors.

Changes in adults

The changes in the female reproductive system as women age are also related to changing hormone levels. As women head into their 40s and 50s, signs of perimenopause occur and eventually, menopause takes place. Perimenopause and menopause are discussed in more depth later in this chapter. The changes in hormone levels can also cause physical changes in the reproductive tract. Vaginal walls become thinner, dryer, and less elastic. Sex can become painful because of these changes. There is a great risk for vaginal yeast infections.

Later in life, senior women are seen most often for neoplasms of the breast, uterus, cervix, and ovaries. In the United States, breast cancer alone will be diagnosed in one in eight women during their lifetime.